ORIGINAL ARTICLE
Radial Head Replacement for Radial Head Fractures
Sameh El sallakh, MD
Objective: This study aimed to analyze the clinical results after
treatment of complex elbow injuries with modular anatomic radial head
prosthesis (MARHP), along with ligament repair and fracture fixation.
Design: Retrospective.
Setting: District teaching hospital.
Patients/Participants: The inclusion criteria were all patients
with traumatic elbow instability after acute fracture or fracture
dislocation, where the radial head was comminuted and irreparable at
the time of surgery (Mason type III) and there was associated valgus
laxity of the elbow. Of 14 patients, 12 with radial head prosthesis
were available for the study.
Intervention: MARHP (Acumed, Hillsboro, OR) was used to
replace irreparable and comminuted radial head fractures when it
was associated with valgus instability.
Main Outcome Measurements: All patients were evaluated
clinically and radiographically for a mean follow-up of 42 months
(range, 22–58 months).
Results: Patients recovered a similar range of motion between
affected and unaffected elbows. Stability was restored to all 12
elbows, and all patients had a good or excellent result according to
Mayo Elbow Performance Index and a disability of the arm,
shoulder, and hand survey. Radiographic measurement revealed
a congruent elbow joint.
Conclusion: The MARHP is effectively restoring stability and
congruency to the elbow joint. There was no evidence of arthritic
radiocapitellar joint, capitellar osteopenia, significant proximal radial
migration of the implant, or any major complications. Outcomes
were optimized by recognition and addressing the associated injuries.
Key Words: radial head, fracture, prosthesis, elbow instability
Level of Evidence: Therapeutic Level IV. See Instructions for
Authors for a complete description of levels of evidence.
(J Orthop Trauma 2013;27:e137–e140)
INTRODUCTION
The radial head is the main stabilizer of the elbow if
the coronoid process is fractured, the medial collateral
ligament is incompetent, or the lateral ulnar collateral
Accepted for publication July 13, 2012.
From the Orthopaedic Department, Tanta University, Tanta, Egypt.
The author has no financial disclosures or conflicts of interest to disclose.
Reprints: Sameh El Sallakh, MD, 2 Catterick Close, London N11 3ES,
United Kingdom (e-mail: saaelsallakh@hotmail.com).
Copyright © 2012 by Lippincott Williams & Wilkins
J Orthop Trauma  Volume 27, Number 6, June 2013
ligament is disrupted.1 The critical role played by the radial
head in overall stability of the elbow and forearm has moti-
vated many orthopaedic surgeons to preserve the radial head
during fracture treatment. Mason type III radial head fractures
include comminuted fractures that are considered unrecon-
structable.2 Surgical management includes radial head exci-
sion with or without radial head replacement.3 Recent studies
have revealed altered kinematics and stability of the elbow
after radial head excision alone owing to adverse biomechan-
ical consequences and a high incidence of arthritis at follow-
up.3 With radial head replacement, the kinematics, stability,
and load transfer of the elbow are equal to those of a native
radial head.4 Poor bone quality, compromised fragment vas-
cularity, and severe comminution often hamper effective
internal fixation leading to suboptimal results.5 In these cases,
prosthetic replacement should be considered, particularly in
the setting of associated fractures and ligament injuries of the
elbow and forearm. The incidence of concomitant injury to
the collateral ligaments of the elbow or interosseous mem-
brane of the forearm exceeds 75% in most series of commi-
nuted radial head fractures.6,7
Implants differ with respect to their head design, stem
design, materials, fixation, and presence of a bipolar or
monopolar design concept. Problems with erosion of the
radiocapitellar or radioulnar interfaces using rigid well-fixed
nonanatomical implants8,9 have lead to the development of an
anatomic design that attempts to replicate the variable shape of
the native radial head and its offset from the axis of the neck.8–10
This retrospective study aimed to analyze the clinical results
after treatment of complex elbow injuries with Modular Ana-
tomic Radial Head System, along with ligament repair and
fracture fixation to facilitate early mobilization of the elbow.
PATIENTS AND METHODS
Fourteen cases had radial head prostheses between
January 2007 and December 2009. Twelve elbows in 12
patients (7 women and 5 men) were available for retrospective
studies. The radial head was resected in all individuals,
followed by replacement arthroplasty with the modular ana-
tomic radial head prosthesis (MARHP) (Acumed, Hillsboro,
OR). MARHP is a modular implant made of highly polished
cobalt chrome and a neck angle of 4 degrees, which is intended
to prevent implant loosening and to maintain the proper
angled relationship between the radial neck and the plane of
the head and the capitellum. An oblong head design has 20
stem options in 5 diameters and 4 collar-height options, which
help to restore the length of the radius and maintain its level in
comparison to the capitellum and coronoid. The grit blasted
stem surface promotes bony on growth, and the broaches are
0.5 mm undersized from the implant stem to ensure a tight
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El sallakh J Orthop Trauma  Volume 27, Number 6, June 2013

press fit and reduce the incidence of lucency.11 The inclusion
criteria were all patients with traumatic elbow instability after
acute (carried out within 3 weeks) fracture or fracture disloca-
tion where the radial head was comminuted and irreparable at
the time of surgery (Mason type III) and there was associated
valgus laxity of the elbow. We excluded the other cases in
which the radial head was reconstructable with internal fixation
either by screws or plate and screws. Six cases were associated
with lateral collateral ligament and 2 cases with medial collat-
eral ligament injuries, which were repaired, and 5 cases were
associated with ulnohumeral or elbow dislocations. Three cases
associated with proximal ulnar fracture and 3 cases associated
with coronoid fractures. We used the unaffected elbow side
in each patient as a control group. The gender, mean age of
39 years (range, 21–61 years), mechanism of injury, side, and
type of radial head fracture with associated injuries were
recorded for these 12 patients (Table1). Patients completed
a Mayo Elbow Performance Index (MEPI),12 a 10-point visual
analog scale pain score (0 = no pain; 10 = severe pain), and
a disabilities of the arm, shoulder, and hand (DASH) survey.13
The clinical evaluation was completed preoperatively and post-
operatively at 3 months, 6 months, and annually afterward.
Operative Technique
The patients were placed in supine position with the
arm supported on a hand table and lateral approach was
adapted with sparing the collateral ligament. In fracture
dislocations, the exposure is through the traumatic opening
in the ligament complex. Templating the radial head before
surgery was done to determine the appropriate level of
resection. The radial head is resected with a microsagittal
saw as close to the surgical neck as possible.
Starting with 5-mm awl to enter the canal and
sequentially using larger broaches until a tight fit is achieved
with the broach. The broaches are 0.5 mm undersized from
the implant stem to ensure a tight press fit. Under power or by
hand, we ream to create a surface where at least 60% of the
radial shaft is in contact with the reamer. Head diameter was
determined by placing the resected head into the sizing
pockets on the impactor base. If between sizes, we select the
smaller diameter. After selecting the trial head and stem, we
align laser marks on the head and stem and assemble using
hand pressure. The stem laser mark is indicated for left and
right, for proper orientation. The trial implant was inserted
into the radius. Proper articulation with the capitellum and the
coronoid was checked. The coronoid needs to be in contact
with the trochlea to ensure proper positioning of the trial. The
trial stems are 0.5 mm undersized from the broaches for ease
of insertion. After determining the correct size head and stem
with the trials, laser marks were aligned and the head and
stem were impacted. The implant was inserted into the radius
using the impactor, and a mallet with ensuring the laser-
etched line on the head was aligned with the lateral aspect of
the radius when the forearm was in neutral position.
Postoperative Protocol
All patients were immobilized initially in a long arm splint
in 90 degrees of flexion with neutral rotation. Motion is initiated
within 7–10 days in all cases. For those with instability noted at
surgery requiring ligament repair, elbow flexion and extension
was performed with the shoulder adducted and the elbow at
the patient’s side to protect the joint from varus stress. These
restrictions were lifted at 6 weeks, postoperatively. Patients were
monitored with serial examinations and radiographs.
Standardized neutral rotation anterior and lateral radio-
graphs of the affected elbow and wrist, and the contralateral
elbow and wrist, were obtained. In some cases, when the
x-ray was not conclusive, a computed tomographic scan was
performed. Radiographs were analyzed and recordings made
of the lateral and medial ulnohumeral space, degree of
proximal radial migration, and change in position of the
implant stem within the canal, lucency about the prosthetic
stem, heterotopic bone formation, and sclerosis/radiolucency
at the radiocapitellar and ulnohumeral joints.
Statistical Analysis
The kinematic measurements of flexion/extension arc,
supination and pronation range of motion, and the

TABLE 1. Type of Radial Head Fracture With Associated Injuries Recorded for the 12 Patients
No. Sex Age Mechanism of Injury Side Fracture Type Associated Injuries
1 F 29 Fall Left Mason type III LCL rupture
2 M 47 Fall Left Mason type III Elbow dislocation, fracture coronoid
3 F 22 Fall Right Mason type III Ulnohumeral dislocation with
LCL rupture
4 F 59 Fall Left Mason type III Elbow dislocation with MCL rupture
5 F 32 Fall Right Mason type III Proximal ulnar fracture
6 M 45 Fall Left Mason type III LCL rupture, distal radial fracture
7 M 39 Fall Right Mason type III Olecranon fracture and LCL rupture
8 F 24 Road traffic accident Right Mason type III Elbow dislocation, slight fracture coronoid
9 F 21 Fall Left Mason type III LCL rupture and MCL rupture
10 M 61 Fall Left Mason type III Ulnohumeral dislocation with
coronoid fracture
11 F 39 Fall Right Mason type III LCL rupture
12 M 49 Fall Right Mason type III Proximal ulnar fracture
F, female; M, male; LCL, Lateral collateral ligament; MCL, Medial collateral ligament.

e138 | www.jorthotrauma.com Ó 2012 Lippincott Williams & Wilkins

J Orthop Trauma  Volume 27, Number 6, June 2013 Radial Head Replacement for Radial Head Fractures

radiographic measures of medial ulnohumeral space, lateral

ulnohumeral space, and proximal migration of the radial shaft
were used to compare between affected and unaffected
elbows. Paired t test were used to compare between the
affected and unaffected elbows in each patient. A significance
level of 0.05 was used.

RESULTS
The outcomes of 12 of 14 implants were available
for review. Follow-up averaged 42 months (range, 22–58
months). Average scores for the study were MEPI, 92 (range,
80–100); visual analog scale for pain 1.1 (range, 0–3),
and DASH, 12 (range, 0–30). The final arc of ulnohumeral
motion averaged 115 degrees (range, 80–150 degrees) with
flexion averaging 135 degrees (range, 90–150 degrees), with
10 degrees of average flexion contracture (range, 0–30
degrees), 75 degrees of pronation (range 45–90 degrees),
FIGURE 1. The x-ray showing radial head prosthesis and plate
and 70 degrees of supination (range, 50–90 degrees). In com-
and screws fixation for ulnar fracture.
parison, the unaffected elbow measured an average flexion/
extension arc of 140 degrees (range, 125–150 degrees), an
average pronation of 80 degrees (range, 60–90 degrees), and important stabilizer of the elbow and forearm in both clinical
an average supination of 80 degrees (range, 60–85 degrees). and biomechanical studies.16–18 Radial head prostheses have
The difference in range of motion between the affected and found a definite place in the treatment of complex radial
unaffected sides for flexion/extension arc, pronation, and head fractures19 and should be used when a radial head resec-
supination was statistically significant (P = 0.014). None of tion would likely cause detrimental effects to the elbow or
the elbows had symptoms or signs of instability at the final wrist. Most patients with nonreconstructable radial head
evaluation. Radiographic measurement of medial and lateral fracture have been shown to have associated lesions to the
ulnohumeral spaces revealed a congruent elbow joint (Fig. 1). elbow.7,20,21 A variety of implants have been used to replace
Analysis of the radiographs of affected and unaffected elbows the radial head. New modular designs have improved sizing
revealed an average lateral ulnohumeral space of 2.5 mm to better reproduce the anatomy of the proximal radius, and
(range, 1–5.5 mm) on the operative side compared with they are easier to insert intraoperatively.22 Several implant
2.6 mm (range, 1.5–6 mm) on the unaffected side with no designs are currently available; however, little data exist on
significant difference (P = 0.21). The medial ulnohumeral the superiority of one design over another. This study did
space of 2.2 mm (range, 1–4 mm) on the operative side com- show the short-term to mid-term results of the clinical and
pared with 2.3 mm (range, 1.5–4.5 mm) on the unaffected radiological outcome of MARHP. There is reestablishment of
side with also no significant difference (P = 0.15). Wrist a congruent elbow joint and restoring the elbow stability.
radiographs revealed an average proximal migration of the There was no evidence of capitellar osteopenia or significant
radius of 0.28 mm (range, 22.6 to 3 mm) on the affected
side compared with an average ulnar positive variance of
0.22 mm (range, 23 to 2.2 mm) on the unaffected side. This
was not statistically significant (P = 0.15). There was no
patient who reported wrist pain. Also, there were small cal-
cification (heterotopic ossification) anterior to the radial neck
that did not restrict motion in 3 patients and lucency around
the stem in 2 patients with no pain specifically referable to the
radial head. Despite this radiolucency, a little change in the
position of the stem was noted within the canal over time
(Fig. 2). Neither significant arthritic changes nor capitellar
osteopenia had been identified at the radiocapitellar joint.

DISCUSSION
The literature has demonstrated that radial head exci-
sion is contraindicated for patients with an incompetent
medial collateral ligament, disrupted forearm interosseous
ligament, or elbow dislocation.4,14 Radial head excision has
fallen out of flavor as a result of complications, such as valgus FIGURE 2. The x-ray showing radial head prosthesis with
elbow instability, elbow stiffness, and proximal migration of loosening around the prosthesis and repair of both lateral and
the radius.15 The radial head has been recognised as an medial ulnar humeral ligaments.

Ó 2012 Lippincott Williams & Wilkins www.jorthotrauma.com | e139

El sallakh
proximal radial migration of the implant. Despite there being
a significant difference between the affected and unaffected
sides in range of movements, the patients recovered the func-
tional range of motion of the elbow. None of the elbows had
symptoms or signs of instability at the final evaluation.
No major complications were identified at an average of
29 months follow-up. Our experience in this study showed
that the MARHP has got several advantages. It has the
advantages of modularity and greater range of head sizes
and collar length. Therefore, we have not had any problem
with overstuffed prosthesis like other studies.16,22 The over-
stuffing of the radiocapitellar joint is associated with radio-
capitellar wear and erosions. It can also lead to subluxation
and abnormal wear of the ulnohumeral joint.8,21,23 Burkhart
et al23 reported mid to long term results after bipolar radial
head arthroplasty. The results were similar to our results in the
MEPI, DASH scoring, and range of movements but with
2 dislocations and 8 degenerative changes of the capitellum,
one with severe erosion and 12 with signs of ulnohumeral
arthrosis. It is critical that the coronoid contacts the trochlea
during this process. The coronoid separated from the trochlea
is an indicator that the collar is too large. The stem of the
MARHP is well fixed to ensure a tight press fit and reduce the
incidence of lucency. This is different from other well-fixed
stem that causes high contact pressure on the opposing artic-
ular cartilage, leading to early failure as in King et al.4
The lucency was not an issue in our study despite it being
recommended by Doornberg et al24 to use loose stem to avoid
loosening and work as a spacer rather than as an integral part
of the bone because loose fit helps to accommodate the
inevitable differences between the prosthetic and native
radial head. In his study, there was a substantial number of
prosthesis showing radiographic evidence of looseness on the
follow-up radiographs. Also, Moro et al25 reported the same
observations. In their series, there were no symptoms or dys-
function that could be directly ascribed to the prosthesis.
CONCLUSIONS
This study reviews the clinical experience with Ana-
tomic Radial Head prosthesis, which is effectively restoring
stability and congruency of the elbows with comminuted and
irreparable radial head fracture and valgus laxity. There was
no evidence of arthritic radiocapitellar joint, capitellar
osteopenia, significant proximal radial migration of the
implant, or any major complications. Patients recovered
a similar range of motion between affected and unaffected
elbows. Outcomes were optimized by recognition and
addressing the associated injuries. Further study with longer
term follow-up and more number of cases will be needed to
find out if these short-term results are maintained over time.
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Ó 2012 Lippincott Williams & Wilkins